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psnet.ahrq.gov/node/50426/psn-pdf
January 01, 2020 - Community pharmacy medication review, death and re-
admission after hospital discharge: a propensity score-
matched cohort study.
September 4, 2019
Lapointe-Shaw L, Bell CM, Austin PC, et al. Community pharmacy medication review, death and re-
admission after hospital discharge: a propensity score-matched cohort s…
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psnet.ahrq.gov/node/42883/psn-pdf
September 01, 2016 - Are we heeding the warning signs? Examining providers'
overrides of computerized drug–drug interaction alerts in
primary care.
September 1, 2016
Slight SP, Seger DL, Nanji KC, et al. Are we heeding the warning signs? Examining providers' overrides of
computerized drug-drug interaction alerts in primary care. PLoS …
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psnet.ahrq.gov/node/46504/psn-pdf
February 22, 2018 - How guiding coalitions promote positive culture change
in hospitals: a longitudinal mixed methods interventional
study.
February 22, 2018
Bradley EH, Brewster AL, McNatt Z, et al. How guiding coalitions promote positive culture change in
hospitals: a longitudinal mixed methods interventional study. BMJ Qual Saf. 2…
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psnet.ahrq.gov/node/38116/psn-pdf
February 18, 2011 - Factors associated with intern fatigue.
February 18, 2011
Friesen LD, Vidyarthi A, Baron RB, et al. Factors associated with intern fatigue. J Gen Intern Med.
2008;23(12):1981-6. doi:10.1007/s11606-008-0798-3.
https://psnet.ahrq.gov/issue/factors-associated-intern-fatigue
Reducing duty hours for physicians in train…
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psnet.ahrq.gov/node/41535/psn-pdf
December 31, 2014 - Understanding and preventing wrong-patient electronic
orders: a randomized controlled trial.
December 31, 2014
Adelman JS, Kalkut GE, Schechter CB, et al. Understanding and preventing wrong-patient electronic
orders: a randomized controlled trial. J Am Med Inform Assoc. 2013;20(2):305-310. doi:10.1136/amiajnl-
201…
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psnet.ahrq.gov/node/60977/psn-pdf
January 08, 2020 - Multiple Levels Involved in Prescribing the Wrong
Medication
September 30, 2020
Chin K, Chau V, Spero H, et al. Multiple Levels Involved in Prescribing the Wrong Medication. PSNet
[internet]. 2020.
https://psnet.ahrq.gov/web-mm/multiple-levels-involved-prescribing-wrong-medication
The Case
A 65-year-old woman co…
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psnet.ahrq.gov/node/849661/psn-pdf
June 28, 2023 - Hurried Team Huddle and Poor Communication: Unsafe
Practice During Anesthesia for Emergency Cesarean
Delivery
June 28, 2023
Curtin A, Schloemerkemper N. Hurried Team Huddle and Poor Communication: Unsafe Practice During
Anesthesia for Emergency Cesarean Delivery. PSNet [internet]. 2023.
https://psnet.ahrq.gov/web…
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psnet.ahrq.gov/node/49580/psn-pdf
March 21, 2009 - Medication Reconciliation Victory After an Avoidable
Error
March 21, 2009
Cutler TW. Medication Reconciliation Victory After an Avoidable Error. PSNet [internet]. 2009.
https://psnet.ahrq.gov/web-mm/medication-reconciliation-victory-after-avoidable-error
The Case
A 91-year-old woman, previously active and indepen…
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psnet.ahrq.gov/node/33705/psn-pdf
January 01, 2011 - Risk Management and Patient Safety
December 1, 2010
Manuel BM, McCarthy JL, Berry WR, et al. Risk Management and Patient Safety. PSNet [internet]. 2010.
https://psnet.ahrq.gov/perspective/risk-management-and-patient-safety
Perspective
In 1990, a Harvard-based research team reported the incidence of medical errors …
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psnet.ahrq.gov/innovation/rescue-improvement-conference-innovation-summary
September 23, 2024 - Rescue Improvement Conference Innovation Summary
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July 23, 2024
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Innovation
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psnet.ahrq.gov/node/33581/psn-pdf
December 15, 2024 - Medication Errors and Adverse Drug Events
December 15, 2024
Medication Errors and Adverse Drug Events. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/medication-errors-and-adverse-drug-events
PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that
they reflect cu…
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psnet.ahrq.gov/node/864868/psn-pdf
March 27, 2024 - Inpatient Transitions of Care: Challenges and Safety
Practices
March 27, 2024
Satake A, McElroy V. Inpatient Transitions of Care: Challenges and Safety Practices. PSNet [internet].
2024.
https://psnet.ahrq.gov/primer/inpatient-transitions-care-challenges-and-safety-practices
Background
Transitions of care occur …
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psnet.ahrq.gov/node/849598/psn-pdf
May 31, 2023 - Remote Response Team and Customized Alert Settings
Help Improve Management of Sepsis
May 31, 2023
https://psnet.ahrq.gov/innovation/remote-response-team-and-customized-alert-settings-help-improve-
management-sepsis
Summary
Seeking a sustainable process to enhance their hospitals’ response to sepsis, a multidiscip…
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psnet.ahrq.gov/node/845360/psn-pdf
March 29, 2023 - Demonstrating the value of a standardized cognitive
assessment tool through the use of interprofessional
rapid safety rounds.
March 29, 2023
Hayes M, Wheeling D, Kaul-Connolly S. Demonstrating the value of a standardized cognitive assessment
tool through the use of interprofessional rapid safety rounds. J Nurs Car…
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psnet.ahrq.gov/node/41451/psn-pdf
October 19, 2012 - Challenges of making a diagnosis in the outpatient
setting: a multi-site survey of primary care physicians.
October 19, 2012
Sarkar U, Bonacum D, Strull W, et al. Challenges of making a diagnosis in the outpatient setting: a multi-
site survey of primary care physicians. BMJ Qual Saf. 2012;21(8):641-648. doi:10.113…
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psnet.ahrq.gov/node/41187/psn-pdf
October 16, 2012 - A pharmacist-led information technology intervention for
medication errors (PINCER): a multicentre, cluster
randomised, controlled trial and cost-effectiveness
analysis.
October 16, 2012
Avery A, Rodgers S, Cantrill JA, et al. A pharmacist-led information technology intervention for medication
errors (PINCER): a …
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psnet.ahrq.gov/node/46893/psn-pdf
March 21, 2018 - Vital signs: trends in emergency department visits for
suspected opioid overdoses- United States, July 2016-
September 2017.
March 21, 2018
Vivolo-Kantor AM, Seth P, Gladden M, et al. Vital Signs: Trends in Emergency Department Visits for
Suspected Opioid Overdoses - United States, July 2016-September 2017. MMWR M…
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psnet.ahrq.gov/node/39549/psn-pdf
March 22, 2011 - The impact of traditional and smart pump infusion
technology on nurse medication administration
performance in a simulated inpatient unit.
March 22, 2011
Trbovich PL, Pinkney S, Cafazzo JA, et al. The impact of traditional and smart pump infusion technology on
nurse medication administration performance in a simul…
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psnet.ahrq.gov/node/43042/psn-pdf
December 18, 2014 - Introduction of surgical safety checklists in Ontario,
Canada.
December 18, 2014
Urbach DR, Govindarajan A, Saskin R, et al. Introduction of Surgical Safety Checklists in Ontario, Canada.
New Engl J Med. 2014;370(11):1029-1038. doi:10.1056/nejmsa1308261.
https://psnet.ahrq.gov/issue/introduction-surgical-safety-ch…
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psnet.ahrq.gov/perspective/ongoing-journey-prevent-patient-falls
December 18, 2024 - Exercise is one of those interventions that reduces fall risks by 23%, so it is a good one to encourage